HomeMy WebLinkAbout0013A 0014( WORKERS' COMPENSATION DECLARATION --- i---- - -s T� - - - -
insureI:here, or a certioffir ficate of Wo kenrtCompensoYoificate of n Tnsuran nt to elf Pl - . APPLICA�t'iO --PO�i B '�lD GPS T - - -
o leu' i�d y the eaL[5�ec. 9800, Lab C) ' • L .-..:__�Q.__...."_._.-__-
� -CLC-y rlu &X Elev. A COUNTY OF LOS ANGELES BUILDING, AND SAFETY
Pocky No. Company A&Em - -- -
0 FOR APPLICANT TO FILL 1N BDDRESG
- Certified copy is hereby furnished. - . - .. ' ADDRESS 610 G1.a35 Drive
�Certified copy is filed with the county building InsI ec- BUILDING - - --
. tion department" : ," .' -`' "„ ` .", ' .ADDRESS 610 looking Glass Drima
Dow :5%15/85 . Applicant 1 I C�JUP, CITY DialTIOnd Bar ZIP - LOCALITY
.: • CERTIFICATE OF EXEMPTION FROM WORKERS' ,.'_ - ._ _.- _ _ _-- -- _
NO. BLDGS. - - NEAREST _- �+� ..__ _... ._.
.... , . ,.... COMPENSATION INSURANCE... -. ... SIZE OF LOT ..Res• NOW ON LOT CROSS ST. H1 Gq1 iJ
(This section on need not be completed if the permit is for one -. _ _. ASSESSOR _
TRACT 5 Btoa ^ Lor ivo. 24 MAP BOOK PAGE - vaRCEt
.. TEL. Lim zoNE - MAP
ied
.
peCisrmify th t in he performance
of the
work
o yhich this --- OWNER - � - NO. - - NO: _ J23 -3.1
y manner ADDRESS 1074 Park _ View _Drive _ _ - R.1 " SPECIAL... ... ... -. - O.
so-as to become subject to the Workers'' Compensation Laws. - - -- - CONDITIONS , _ . u
Hare Appticam V Covina ZIP 91722 _; oa
ZTICE TO APPLICANT. lf, after making this Certificate of ARCHITECT OR tEi." - _ - "'
ENGINEER DISTRICT GROUP.- TYPE __ _ FIRE PROCESSED @Y
.empt you- should became subject do the Worked CONST - ZONE
W
Compensation. provisions of'the t.obar Code, You-must fdrth- ADDRESS 314 .N 1St A LTe CdCll -- Q. -- - ��
with comply witk such provisions ar this permit shall be ,- -- - -- - --- - ----- TEL— '-- STATISTICAL CLASSIFICATION APT. CONDO - Z-
deemed revoked; . , ., - ' CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LK. CLASS
I hereby affirm that L am licensed under provisions of Chapter 9 ADDRESS NO.. B
(commencing with Section 7000) of Division 3 of the Business and .... LIC SEWER GAAP - -' -
Profess ons.Code,.and my license is in full force and effect. CITY CLASS - BK. - - - YAIWATLOFf
_ 50. FT. NO OF PK} OF CHECK
_ License Number .3� $0 -,Lic. Class B' - - SRF - 1786 -_ STORIES--1- —FAMILIES 1 -- - ONE -
85 DESCRIPTION OF WORK VALUA
z 0 0 t 3A
44�7
Cantfaclaf AItt1 GROi Date 515 'NEW
S 81,106
O . _. _ _.. --- ------._--.- ADD '
tam exempt under Sec. -- --- - _.
ALTER
2b L>.i�s
B.BP-C for this reason .REPatR_-
__.. .Date. - USE OF -
EXISTING BLDG. DEMOL
__r. .. .. APPLICANt. _ - TEL FINAL
-
Sigrwture OWNER-BUILDER DECLARATION _ PRINT NO
.- I. hereby affirm that 1 are exempt from the Contractors license - -- - - - ---- -- -- -- - -- f -
Low for the following reason (Section 7031.5, Business andE ,-- ADDRESS RNC%L --
`erafessnons Code)!-"-,
BUILDING • •�.' 2.=
I n
as ower of the property, or my employees with ADDRESS _ - G.G
"� wages asiFeir sore coinpensotion, wflI-do the work and ---_ .— .—__ .�.__ -.___ _._ �. - _.-_ .. __... —.
the structureis not intended or offered for sale (Section LOCALITY 0522-85
704x, Business-amfAofess+ansfvdaj -----. _. _._.- MOVING --- - - -- '--- - _Tit-___.-
n 1, as owner of the property, am exclusively contracting CONTRACTOR - - NO-
.with -licensed
O-.with--licensed- contractors to construct the project jSec-
.. —:-- - ---------- '---- - i.
tion 7044, Business and Professions Code). ADDRESS
HWV
REQUIRED YARD .TOTAL SETBACK-_ ... _. ,.. ...
—CONSTRUCTION -LENDING _. SETBACK PROP. UNE .WIDTH_'
I hereby affirm that there is a construction lending agency for FRONT -
-the-performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.).
(7B23T3I1>lrIitci� I311±1D1S P.L. _ —__ -
e
Lender's Name - LDMA Ref. # ..
$ Le�dars ndare-- 399-PaXk-Ave: - NiYi, 10043 P.C. Fee $ 268.65 Permit Fee - 451-.50 oil.
1 certify th have-'ea _this..applicatian and state that.ihe -__ . _ - -_ - Iss - Fee - LDMA P/C # - -
a above in m do a oned. I agree to comply with all County Investigation Fee
g ordi_na es d t e laws relating to builV.wn,�.Ul
ion, _ Total fee G -� - - CDMA -Perm # -
u and - re a n -representatives of thiupo th nt oned property for ins/ Izm, $109.00. -55.00
SEE REVERSE FOR EXPLANATORY LANGUAGE -
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